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APPLICATION FOR WELLIPUMP PERMIT <br /> 1°il�:IAN JOAQUIN COUNTY PUBLIC HEALTH SERVI( Mt <br /> ENVIRONMENTAL HEALTH DIVISION P E BY E T <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 RECEIVED <br /> (209) 488-3420 .� 1 ! ( n 199fi <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN ! u." , '..! iIV COUNTY <br /> (Complete in Triplicate) PUrIIC HEOAL FH SERVICES <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the@LY1QR��lhii�l'a[>Gilltld:'d�^i VSdu�lis <br /> made in compliance with San Joaquin County Development Title, Chapter 9- 1115 . 3 and the Standards of San Joaquin County Public Health <br /> Services , Environmental Health Division . <br /> Job Address/or APN# PNS z� , City ParceL Size/APN# ✓J <br /> Owner ' s Nam _ � /�//,,,2, f7 .� �Address ,g,J �{�'A�L� �U/r �1 Phone # < 9 SS <br /> Contractor///!��>�C�-��� //✓h ' " -�ddress IoW, r !i • /A?//7pf,G� u/ � Lic# /YgWL2 / Phone # �� 7 <br /> Sub Contractor / /lzw�,//D� ///I�LG/tel Address//,7% .Z�✓E Lic# '// f1..�/O Phone # �/� <br /> iic.y <br /> TYPE Of WELL/PUMP : [7 NEW WELL [I REPLACEMENT WELL CI MONITORING WELL # [I OTHER <br /> [I DESTRUCTION [I OUT -Of - SERVICE WELL [I GEOPHYSICAL WELL # SOIL BORING _ <br /> CI INSTALLATION [7 WELL SYSTEM REPAIR [I CROSSCONNECT REPAIR [7 VAPOR EXTRACTION WELL # <br /> [7 New 17 Repair H . P . DEPTH PUMP SET FT . FIRST NATER LEVEL <br /> ( TYPE OF PUMP ) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INDUSTRIAL ❑ OPEN BOTTOM DIA , OF WELL EXCAVATION D ] A , OF CONDUCTOR CASING <br /> i [I DOMESTIC/PRIVATE [I GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA , OF WELL CASING <br /> C7 PUBLIC/MUNICIPAL [7 DRIVEN DEPTH OF GROUT SEAL /071'Yp �22�0�_ SPECIFICATION <br /> [I IRRIGATION/AG Q OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME J� <br /> ] MONITORING GROUT SEAL PUMPED : [I Yes ANo CONCRETE PEDESTAL BY DRILLER : [7 Yes [I No <br /> APPROX. DEPTH 3.�J <br /> LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> 1 hereby certify that I have prepared this application and that the work wi LL be done in accordance with San Joaquin County Ordinances , <br /> State Laws , and Rules and Regulations of the San Joaquin County . Home owner or Licensed agent ' s signature certifies the following : " 1 <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN ' S COMPENSATION <br /> Laws of California . " Contractor ' s hiring or sub-contracting signature certifies the foLLowing : " 1 certify that in the performance <br /> of the work for which this permit is issued, 1 shall employ persons subject to WORKMAN ' S COMPENSATION Laws of CaLifornia . " THEAPPLICANT <br /> MUST CALL 24 HOURS IN ADVANCE FOR ALL EOUIRED INSPECTIONS AT (209) 468.3423 . Complete drawing (aattt Lower areaprovided . ��// <br /> - Signed X TitleT�•�` � Date/Za <br /> PLOT PLAN (Draw to Sca Le) Scale- " to <br /> Ila'I <br /> DEPARTMENT USE ONLY �f <br /> Application Accepted By Date G �F`" Area <br /> Grout Inspection By Date Pump Inspection By Date <br /> �i,,' <br /> Destruction Inspection By Date Comments : S �� 3 S <br /> i <br /> i <br /> ACCOUNTING ONLY: AID# fAC# <br /> I � PE CODES FEE IINFO( AMOUNT REMITTED CHECKIWCASH RECEIVED BY DATE PERMITISER/VICE REDDEST NUMBER INVOICE <br /> f <br />